Presentation is loading. Please wait.

Presentation is loading. Please wait.

Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula YK Fong, Queen Mary Hospital.

Similar presentations


Presentation on theme: "Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula YK Fong, Queen Mary Hospital."— Presentation transcript:

1 Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula YK Fong, Queen Mary Hospital

2 Agenda Introduction – Etiology and pathogenesis – Classification Management approach of anal fistula – Assessment – Surgical options Recent advances in surgical treatment

3 Etiology and Pathogenesis Cryptoglandular (90%) – Extension of sepsis from infected anal glands in the intersphincter space Non-cryptoglandular – Crohn’s disease – Tuberculosis, actinomycosis – Malignancy – Hidradenitis suppurativa – Radiation – HIV infection – Immunocompromised (chemotherapy/ diabetes)

4 Classification 1) Intersphincteric 2) Transphincteric 3) Suprasphincteric 4) Extrasphincteric

5 Anal Fistula Classification Complex: Treatment poses a high risk of incontinence – Postoperative recurrence – Multiple tracts – Tract crosses >30-50% of external sphincter muscle – Anterior in females – Pre-existing incontinence American Gastroenterological Association

6 Complex Anal Fistula - Management Approach Assessment – To rule out ongoing anorectal sepsis – To delineate the anatomy of fistula tracts To look for non-cryptoglandular causes To look for any causes of poor wound healing – Immunocompromised – steroid application Definitive treatment

7 Principles of Treatment Control of sepsis Closure of fistula Maintenance of continence

8 Surgical Treatment Options Conventional approaches – Cutting Seton placement – Staged fistulotomy – Anorectal advancement flap Continence preserving approaches – Fibrin glue – Anal fistula plug – Ligation of Intersphincteric Fistula Tract (LIFT) – Video-Assisted Anal Fistula Treatment (VAAFT)

9 LIFT Procedure (Ligation of Intersphincteric Fistula Tract ) – Rojanasakul et al. from Bangkok in 2007 – Success rate: 17/18 (94.4%) Rojanasakul, Tech Coloproctol 2009

10 LIFT Procedure: A Simplified Technique for Anal Fistula

11 Rationale of LIFT Procedure Prevention of recurrent sepsis – Avoid entrance of fecal particles via internal opening – Remove intersphincteric fistula tract Intermittent closed septic foci and persistent sepsis due to compression between sphincter muscles

12 LIFT Procedure Less injury to anal sphincter Short hospital stay Short healing time Primary healing rate 82.2% (37/45) Shanwani et al DCR 2010

13 BioLIFT Procedure A modification of LIFT Procedure Placement of biologic mesh in the intersphincteric space – Barrier to re-fistulization C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

14 BioLIFT Procedure Bioprosthetic grafts – Tolerate contamination – Remodeling without a foreign body reaction Healing rate: 94% (29/31) C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

15 BioLIFT Procedure Potential drawbacks of the BioLIFT technique – Requires extensive dissection in the intersphincteric space – High cost of the bioprosthetic materials

16 Unsuitable Cases for LIFT Procedure External opening at intersphincteric groove Abscess cavity in intersphincteric space (friable tract) Large internal opening Specific causes: TB, Crohn’s

17 VAAFT (Video-Assisted Anal Fistula Treatment) Karl Storz endoscope A small-calibered rigidscope equipped with an optical channel, a working channel and an irrigation channel

18 VAAFT

19 VAAFT: Meinero technique Ablation of the fistula tract with unipolar electrode Closure of the internal opening with stapler Injection of cyanoacrylate into the fistula tract Meniero P. Tech Coloproctol 2011

20 VAAFT: Meinero technique 98 patients with complex fistula Performed under spinal anesthesia Operation time: 30 to 120 minutes Primary healing: 72 patients (73.5%) Healing time: 2-3 months No major complication or fecal incontinence Meniero P. Tech Coloproctol 2011

21 Conclusion Management principles of complex anal fistula – Detailed assessment to exclude underlying disease – Anatomical +/- functional assessment – Tailored treatment To control and eradicate sepsis (stages) To remove tract and close internal opening To preserve continence

22 Thank you

23 Assessment Clinical – Digital examination – Examination under anesthesia (EUA) – Anal manometry Radiological – Endoanal ultrasound – Magnetic resonance imaging

24 LIFT Procedure Prospective observational study All cryptoglandular infections May 2007 to September patients – 33 transsphincteric – 12 complex Median follow-up: 9 (range, 2-16) months Primary healing: 37/45(82.2%) Median healing time : 7 (range, 4-10) weeks Shanwani et al DCR 2010

25 QMH Experience Since January 2009 – 25 patients 24 transphincteric fistula 1 suprasphincteric fistula – 15 recurrenct Median operating time: 39 minutes (range 15-73) Median hospital stay: 1 day Perianal incision healing time: 14 days Closure of external opening: 31 days Median follow-up 9.8 months (range ) 2/25 (11%) recurrent rate

26 VAAFT To identify the internal opening under direct endoscopic view and then close it with suturing or stapler To ablate or remove the granulation tissue along the fistula tract To fill the fistula tract with bio-prosthetic material

27 27


Download ppt "Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula YK Fong, Queen Mary Hospital."

Similar presentations


Ads by Google